| NPI | 1407409535 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: MI 4704327815) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: MI 4704327815) |
| Enumeration Date | 2019-07-17 |
| Last Update Date | 2024-10-17 |